2012-01-03_PR_Packet - Laserfiche WebLink

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Skating 0 Roseville School of Dance Ages 5 and up Mondays 6-.15-7pm Roseville Fitness Room n � -June ° li u $79. Roseville Res $71 J Ra I fflen: A, ........70m,!, Pafks and Recreahion Calling ALL boys'.'.'. like thin i p Hop dance onTV9. instructor i and learn how to hip hop dance m this ll boys class'. 1 dance abi liti 1 1 .................................................................................................................................................................................................................................................................................................................................................................................................................... Register: Online: www.cityofroseville.com/parks—By Phone: 651-792-7110 Fax: 651-792-7100 In Person:Monday-Friday 8-4:30 p.m. or By Mail: Checks payable to Roseville Parks&Recreation Send completed registration form with check or credit card payment to: Roseville Parks and Recreation,2660 Civic Center Drive,Roseville MN 55113 Boys Hip Hop 2012 prog#2901.161 Dancers Name: Phone Number: Address: City/State/Zip: Email: Date of Birth: Form of payment: Cash (in person only) Check Visa Master Card Ameri Express Credit Card Number Exp.Date Cardholder's Name Cardholder's Signature Liability waiver:I understand that participation in this activity is completely voluntary.I recognize that there are risks in my participation in this activity.I agree to accept those risks.I also agree,in consideration for my being allowed to participate in this activity,and on behalf of myself,my heir,executors,administrators and assigns,to release and discharge the City of Roseville,sponsor(s)of the event or activity,and their officers,employees,agents,successors and/or assigns from liability for any and all injury,damage or loss that is or may arise from my participation in this activity.Data Practices Act Notice:Pursuant to the Minnesota Government Data Practices Act,you are being requested to furnish certain information that is classified as private under the Act.The City collects such information in order to properly process requests to participate in activities.You may refuse to provide such information,but such a refusal may affect your ability to participate.The information will be maintained by the City Park and Recreation Department,and may be accessible to anyone in the Department,or in other Departments of the City.